The following questions ask how you feel about your quality of life, health, or other areas of your life. Please choose the answer that appears most appropriate. If you are unsure about which response to give to a question, the first response you think of is often the best one. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last four weeks.

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* 1. Please provide your personal information

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* 2. How would you rate your overall quality of life?

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* 3. How satisfied are you with your overall health?

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* 4. How much do you need medications to function in your daily life?

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* 5. The following questions ask about how much you have experienced certain things in the last four weeks.

  Not at All A Little A Moderate Amount Very Much Extremely/An Extreme Amount
How much do you enjoy life?
To what extent do you feel your life to be meaningful?
How well are you able to concentrate?
How safe do you feel in your daily life?
How healthy is your physical environment?

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* 6. The following questions ask about how completely you experience or were able to do certain things in the last four weeks.

  Not At All A Little Moderately Mostly Completely
Do you have enough energy for everyday life?
Are you able to accept your bodily appearance?
Have you enough money to meet your needs?
How available to you is the information that you need in your day-to-day life?
To what extent do you have the opportunity for leisure activities?

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* 7. How well are you able to get around?

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* 8. The following questions ask about how completely you experience or were able to do certain things in the last four weeks.

  Very Dissatisfied Dissatisfied Neither Dissatisfied Nor Satisfied Satisfied Very Satisfied
How satisfied are you with your sleep?
How satisfied are you with your ability to perform your daily living activities?
How satisfied are you with your capacity for work?
How satisfied are you with yourself?
How satisfied are you with your personal relationships?
How satisfied are you with the support you get from your friends/family?
How satisfied are you with the conditions of your living place?
How satisfied are you with your access to quality health services?
How satisfied are you with your transportation?

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* 9. How often do you have negative feelings such as blue mood, despair, anxiety, depression?

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